Provider Demographics
NPI:1972581999
Name:LEAKE, DAVID CAMPBELL (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CAMPBELL
Last Name:LEAKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2408 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3209
Mailing Address - Country:US
Mailing Address - Phone:203-752-3100
Mailing Address - Fax:203-752-9291
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-752-3100
Practice Address - Fax:203-752-9291
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1972581999Medicaid
CTD400196496Medicare Oscar/Certification
CT1972581999Medicaid